We are writing to tell [1] that the Internal Revenue Service (IRS) has asked to take money from [2][3] because [4] them money. The IRS calls this action a Notice of Levy.

What You Need To Do

To help decide the correct amount of money to send the IRS, [5] [6] complete the enclosed Exemption Statement and return it within 10 days from the date [7] this letter. [8]. Send the completed statement to:

[9]

If we do not receive the completed statement within the 10-day period, IRS will only allow an exemption amount of $[10].

If [11] more information or [12] any questions, please contact [13] local IRS office.

Enclosure:

Exemption Statement

Fill-ins:

XXX-XX-XXXX                                             Page 2 of 2

STATEMENT OF EXEMPTIONS AND FILING STATUS
(TO BE COMPLETED BY TAXPAYER)

My filing status for my Income Tax Return is (check one):

I also claim additional exemption(s) for:

I certify that I can claim the people named below as personal exemptions on my income tax return and that none are claimed on another Notice of Levy. No one I have listed is my minor child to whom (as required by court or administrative order) I make support payments that are already exempt from levy. I understand the information I have provided may be verified by the Internal Revenue Service. Under penalties of perjury, I declare that this statement of exemptions and filing status is true.

Name of dependents claimed as exemptions:

                                                                         

Taxpayer's Signature                       Date